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Overview Help
A BETTER WAY TO TAKE CARE OF BUSINESS
2022 PLANS AND PRODUCTS | CALIFORNIA
Complete Suite plan comparison chart
Use this overview of our Complete Suite portfolio to easily explore a wide range of
Kaiser Permanente plans. This interactive tool also enables you to get quick side-by-side
comparisons of the different plans we have to offer.
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Compare. Select. Administer. It’s that easy.
With Complete Suite, we’ve done the work for you. We’ve compiled our most popular
standard midmarket plans in this interactive plan comparison chart, which allows you
to easily compare core and value-added supplemental plan benefits. And with a single
request, you can get binding quotes in a matter of minutes for up to 1,000 members.
New in 2022 — Virtual Complete™ Plans
With a Kaiser Permanente Virtual Complete™ plan, your employees can get affordable, high-
quality, personalized care in a variety of ways. They have flexibility in how they choose to get care —
taking full advantage of our many no-cost virtual care options while still having primary care access
to in-person care whenever they need it.
Choice Products Portfolio Redesign
The new portfolio includes 6 new PPO plans with deductibles between $500 and $2,000 plus
a new $3,000 deductible HSA-qualified PPO. We have 3 new point-of-service (POS) options
designed to better meet the needs of our customers.
Other Changes for 2022
• Deductible HMO HO 13872/13873 has been added to provide an additional option for
optical coverage.
• Several plans have higher out-of-pocket maximums, lab, and X-ray cost shares in order to
maintain affordability.
• The maximum cost share for specialty drug has increased from $200 to $250 on all plans to
maintain affordability.
• Deductible HMO XD plans 8800/8801 and 8810/8811 have been updated to eliminate the
pharmacy deductible, and add an incentive for using mail-order prescription delivery.
• The cost share for an office visit has been lowered from $50 to $40 on HSA-Qualified HDHP
HMO 8122/8125. New plan ID is 13877/13878.
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How to compare plans
With our Complete Suite interactive plan comparison chart, you can choose up to 3 plans at
a time and get as many comparisons as you’d like.
To get a comparison:
1. Click the Overview tab at the top of the page.
2. Check the box next to each plan you’d like to compare, then click the Compare plans
button at the top-right corner of the page.
3. To remove a plan from your comparison, click the checked box to clear it.
To remove all plans selected, click the Reset button at the bottom of the page.
You can also get more detailed information about each plan type by clicking the tabs at the top of the
page — HMO, DHMO (deductible HMO), CDHC (consumer-directed health care), or POS/PPO (point-of-service/
participating provider organization). To go back to the plan comparison page at any time, simply click the
Overview tab at the top-left corner of the page.
Are you viewing this on a mobile device?
The interactive features work best when you download to a desktop or use an application such as Adobe Reader.
The plan summary highlights the most frequently asked-about benefits and is for illustration purposes only. For a complete description,
please refer to the appropriate Evidence of Coverage or Certificate of Insurance booklet or contact your broker or Kaiser Permanente
account manager.
Information may have changed since publication.
Ready to connect?
Check out our 2022 plans and request a quote from your
Kaiser Permanente representative today.
The HMO tier of the point-of-service (POS) plan is underwritten by Kaiser Foundation Health Plan, Inc. (KFHP). Kaiser Permanente Insurance
Company (KPIC) underwrites the participating and nonparticipating provider tiers of the POS plan and the PPO plan. KPIC is a subsidiary of
Kaiser Foundation Health Plan, Inc.
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2022 Complete Suite plans
Select the plans that you want to compare. You can choose up to 3 at a time.
Plans selected:
HMO DHMO CDHC POS/PPO
Compare plans
HMO plan families
NCAL / SCAL plan ID — office visit/hospital inpatient/out-of-pocket maximum
HMO High
1, 2
9961/9962 — $10/$0/$1,500
9965/9966 — $15/$0/$1,500
10003/10004 — $20/$0/$1,500
10650/10652
3
— $20/$0/$1,500
10011/10012 — $15/$250/$1,500
10015/10016 — $20/$250/$1,500
10678/10679
3
— $20/$250/$1,500
10048/10049 — $25/$250/$1,500
10052/10053 — $20/$500/$1,500
9970/9972 — $25/$500/$1,500
10680/10681
3
— $25/$500/$1,500
9981/9982 — $30/$500/$1,500
HMO Mid
1, 2
9983/9984 — $20/$250/$2,000
10682/10683
3
— $20/$250/$2,000
9989/9990 — $20/$500/$2,500
9930/9931 — $25/$500/$2,500
9987/9988 — $30/$250/$2,000
9991/9992 — $30/$500/$2,500
10684/10685
3
— $30/$500/$2,500
HMO Low
1, 2
9955/9956 — $20/$250/$3,000
9957/9958 — $30/$250/$3,000
9959/9960 — $20/$500/$3,000
9967/9969 — $30/$500/$3,000
9973/9974 — $30/$500/$3,000
9979/9980 — $30/$500/$3,500
9977/9978 — $40/$500/$3,000
9942/9943 — $40/$500/$3,500
13058/13059
4
— $40/30%/$4,000
Reset
Clear all plans selected
1. HMO Low/Mid/High plans — HMO High, Mid, and Low designations are driven by the plans’ out-of-pocket maximum levels. High plans offer the
lowest out-of-pocket maximums. Low plans offer the highest out-of-pocket maximums. 2. Traditional HMO — Pay a simple copay for most covered
services. 3. Available with optical hardware allowance. 4. Coinsurance HMO — Pay office visit copays; coinsurance for most other services.
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2022 Complete Suite plans
Click on the specific plan name to see your options for that plan.
Plans selected:
HMO DHMO CDHC POS/PPO
Compare plans
Deductible HMO (DHMO) plan families
NCAL / SCAL plan ID — deductible/office visit/hospital inpatient
Deductible HMO HO
1
8776/8777 — $250/$10/10%
8780/8781 — $500/$20/10%
8782/8783 — $750/$25/20%
13872/13873
4
— $750/$25/20%
8784/8785 — $1,000/$20/20%
10690/10691
4
— $1,000/$20/20%
8790/8791 — $1,500/$20/20%
10692/10693
4
— $1,500/$20/20%
13046/13047 — $2,000/$20/20%
8794/8795 — $2,500/$20/20%
8792/8793 — $1,500/$40/30%
10208/10209 — $3,000/$40/30%
Deductible HMO XD
2
8796/8797 — $250/$10/10%
8800/8801 — $500/$20/20%
8808/8809 — $750/$25/20%
8804/8805 — $1,000/$20/20%
8810/8811 — $1,000/$30/30%
8814/8815 — $1,500/$20/20%
8818/8819 — $2,000/$20/20%
8816/8817 — $1,500/$40/30%
8820/8821 — $2,500/$40/30%
8822/8823 — $3,000/$40/30%
13864/13865 — $3,500/$40/30%
(formerly 8824/8825)
13868/13869 — $4,000/$40/30%
(formerly 11904/11905)
Virtual Complete
13770/13771 — $2,000/$30/20%
13774/13775 — $2,500/$40/20%
13778/13779 — $3,000/$40/30%
13782/13783 — $4,000/$50/30%
13786/13787 — $5,000/$50/40%
Deductible HMO CDO
3
13860/13861 — $5,000/$50/30%
(formerly 9151/9163)
13858/13859— $5,500/$50/40%
(formerly 9150/9161)
Reset
Clear all plans selected
1. Deductible HMO HO — Most services are covered at a copay or coinsurance. A deductible applies to hospital services, such as inpatient
hospital, outpatient surgery, and emergency room services. 2. Deductible HMO XD — Provider office visits and pharmacy are covered at a copay
or coinsurance. A deductible applies to most other services. 3. Deductible HMO CDO — Preventive care is covered at no cost. A deductible applies
to most services, including pharmacy. 4. Available with optical hardware allowance.
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2022 Complete Suite plans
Click on the specific plan name to see your options for that plan.
Plans selected:
HMO DHMO CDHC POS/PPO
Compare plans
Consumer-directed health care (CDHC) plans
NCAL / SCAL plan ID — deductible/office visit/hospital inpatient
HSA-qualified HDHP HMO
1
12189/12191 — $1,400/$20/$250
12195/12196 — $1,500/10%/10%
12168/12167 — $2,800/$0/$0
12190/12193 — $2,000/$30/$250
11908/11909 — $2,500/$30/$250
12187/12188 — $2,800/$30/30%
10426/10427 — $3,500/$30/30%
13877/13878 — $4,500/$40/40%
(formerly 8122/8125)
13854/13855 — $4,500/40%/40%
(formerly 8126/8127)
13850/13851 — $5,500/$50/40%
(formerly 10160/10161)
Deductible HMO plans with HRA
2
8759/8760 — $1,000/$20/20%
8761/8762 — $1,500/$20/20%
8763/8764 — $2,000/$20/20%
8765/8766 — $2,500/$20/20%
7823/7824 — $3,000/30%/30%
13050/13051 — $3,500/30%/30%
13822/13823 — $4,000/30%/30%
(formerly 13054/13055)
Reset
Clear all plans selected
1. HSA-qualified HDHP HMO — All services, except preventive services, are subject to a deductible. 2. Deductible HMO — Plans with HRA have XP
accumulation, meaning pharmacy is covered at a copay or coinsurance. A deductible applies to most other services.
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2022 Complete Suite plans
Click on the specific plan name to see your options for that plan.
Plans selected:
HMO DHMO CDHC
POS/PPO
Compare plans
POS/PPO plans
NC AL / SCAL plan ID — deductible by tier/office visit by tier
POS plans
13886/13887 — $0/$500/$1,000; $20/$35/40%
13890/13891 — $0/$1,000/$2,000; $25/$50/40%
13894/13895 — $0/$1,500/$3,000; $30/20%/50%
PPO plans
13898/13899 — $500/$1,500; $20/40%
13902/13903 — $750/$1,750; $30/40%
13906/13907 — $1,000/$2,000; $35/40%
13910/13911 — $1,500/$3,000; $35/40%
13914/13915 — $2,000/$4,000; $40/50%
HSA Qualified 13918/13919 — $3,000/$5,000; $40/40%
Reset
Clear all plans selected
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Compare plans
Plans selected:
Complete Suite category
HMO
HMO High
1
HMO High
1
HMO High
1
HMO High
1
HMO High
1
NCAL/SCAL plan ID 9961/9962 9965/9966 10003/10004 10650/10652 10011/10012
Plan deductible
(individual/family)
None None None None None
Out-of-pocket maximum
(individual/family)
$1,500/$3,000 $1,500/$3,000 $1,500/$3,000 $1,500/$3,000 $1,500/$3,000
Telehealth
2
No charge No charge No charge No charge No charge
Preventive care No charge No charge No charge No charge No charge
Primary and specialty
care visit
$10 $15 $20 $20 $15
Hospital inpatient
(per admission)
No charge No charge No charge No charge $250 per admit
Outpatient surgery
(per procedure)
$10 $15 $20 $20 $15
Emergency care $100 $100 $100 $100 $100
Prescription drugs
Generic $10 $10 $10 $10 $10
Brand $20 $20 $20 $20 $30
Specialty
20%, not to
exceed $250
20%, not to
exceed $250
20%, not to
exceed $250
20%, not to
exceed $250
20%, not to
exceed $250
Emergency ambulance
services (per trip)
$50 $50 $50 $50 $50
CT/PET/MRI (per procedure) No charge No charge No charge No charge No charge
Lab/X-ray (per encounter) No charge No charge No charge No charge No charge
Durable medical
equipment
20% 20% 20% 20%
20%
Fertility services
Same as medical
benefit
Same as medical
benefit
Same as medical
benefit
Same as medical
benefit
50%
Prenatal care and
well-baby visits
No charge No charge No charge
No charge No charge
Optical hardware Not covered Not covered Not covered
$150 hardware
allowance/12 months
Not covered
Prosthetics and orthotics No charge No charge No charge No charge No charge
1. Traditional HMO — Pay a simple copay for most covered services. 2. Telehealth — Telehealth services include scheduled phone and video visits, as
well as email consultations, when appropriate and available. These features are available when you get care from Kaiser Permanente providers.
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Compare plans
Plans selected:
Complete Suite category
HMO
HMO High
1
HMO High
1
HMO High
1
HMO High
1
HMO High
1
NCAL/SCAL plan ID 10015/10016 10678/10679 10048/10049 10052/10053 9970/9972
Plan deductible
(individual/family)
None None None None None
Out-of-pocket maximum
(individual/family)
$1,500/$3,000 $1,500/$3,000 $1,500/$3,000 $1,500/$3,000 $1,500/$3,000
Telehealth
2
No charge No charge No charge No charge No charge
Preventive care No charge No charge No charge No charge No charge
Primary and specialty
care visit
$20 $20 $25 $20 $25
Hospital inpatient
(per admission)
$250 per admit $250 per admit $250 per admit $500 per admit $500 per admit
Outpatient surgery
(per procedure)
$20 $20 $25 $100 $100
Emergency care $100 $100 $100 $100 $100
Prescription drugs
Generic $10 $10 $10 $15 $15
Brand $30 $30 $30 $35 $35
Specialty
20%, not to
exceed $250
20%, not to
exceed $250
20%, not to
exceed $250
30%, not to
exceed $250
30%, not to
exceed $250
Emergency ambulance
services (per trip)
$50 $50 $50 $100 $100
CT/PET/MRI (per procedure) No charge No charge No charge $50 $50
Lab/X-ray (per encounter) No charge No charge No charge $10 $10
Durable medical
equipment
20% 20% 20% 20% 20%
Fertility services 50% 50% 50% 50% 50%
Prenatal care and
well-baby visits
No charge No charge No charge No charge No charge
Optical hardware Not covered
$150 hardware
allowance/12 months
Not covered Not covered Not covered
Prosthetics and orthotics No charge No charge No charge No charge No charge
1. Traditional HMO — Pay a simple copay for most covered services. 2. Telehealth — Telehealth services include scheduled phone and video visits,
as well as email consultations, when appropriate and available. These features are available when you get care from Kaiser Permanente providers.
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Overvi ew HMO DHMO CDHC POS/PPO
Compare plans
Plans selected:
Complete Suite category
HMO
HMO High
1
HMO High
1
HMO Mid
1
HMO Mid
1
HMO Mid
1
NCAL/SCAL plan ID 10680/10681 9981/9982 9983/9984 10682/10683 9989/9990
Plan deductible
(individual/family)
None None None None None
Out-of-pocket maximum
(individual/family)
$1,500/$3,000 $1,500/$3,000 $2,000/$4,000 $2,000/$4,000 $2,500/$5,000
Telehealth
2
No charge No charge No charge No charge No charge
Preventive care No charge No charge No charge No charge No charge
Primary and specialty
care visit
$25 $30 $20 $20 $20
Hospital inpatient
(per admission)
$500 per admit $500 per admit $250 per admit $250 per admit $500 per admit
Outpatient surgery
(per procedure)
$100 $100 $100 $100 $250
Emergency care $100 $100 $100 $100 $100
Prescription drugs
Generic $15 $15 $15 $15 $15
Brand $35 $35 $30 $30 $35
Specialty
30%, not to
exceed $250
30%, not to
exceed $250
30%, not to
exceed $250
30%, not to
exceed $250
30%, not to
exceed $250
Emergency ambulance
services (per trip)
$100 $100 $100 $100 $100
CT/PET/MRI (per procedure) $50 $50 $50 $50 $50
Lab/X-ray (per encounter) $10 $10 $10 $10 $10
Durable medical
equipment
20% 20% 20% 20%
20%
Fertility services 50% 50% 50% 50% 50%
Prenatal care and
well-baby visits
No charge No charge No charge No charge No charge
Optical hardware
$150 hardware
allowance/24 months
Not covered Not covered
$150 hardware
allowance/24 months
Not covered
Prosthetics and orthotics No charge No charge No charge No charge No charge
1. Traditional HMO — Pay a simple copay for most covered services. 2. Telehealth — Telehealth services include scheduled phone and video visits,
as well as email consultations, when appropriate and available. These features are available when you get care from Kaiser Permanente providers.
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Overvi ew HMO DHMO CDHC POS/PPO
Compare plans
Plans selected:
Complete Suite category
HMO
HMO Mid
1
HMO Mid
1
HMO Mid
1
HMO Mid
1
HMO Low
1
NCAL/SCAL plan ID 9930/9931 9987/9988 9991/9992 10684/10685 9955/9956
Plan deductible
(individual/family)
None None None None None
Out-of-pocket maximum
(individual/family)
$2,500/$5,000 $2,000/$4,000 $2,500/$5,000 $2,500/$5,000 $3,000/$6,000
Telehealth
2
No charge No charge No charge No charge No charge
Preventive care No charge No charge No charge No charge No charge
Primary and specialty
care visit
$25 $30 $30 $30 $20
Hospital inpatient
(per admission)
$500 per admit $250 per admit $500 per admit $500 per admit
$250 per day
up to 3 days
Outpatient surgery
(per procedure)
$250 $100 $250 $250 $125
Emergency care $100 $100 $100 $100 $100
Prescription drugs
Generic $15 $15 $15 $15 $10
Brand $35 $30 $35 $35 $30
Specialty
30%, not to
exceed $250
30%, not to
exceed $250
30%, not to
exceed $250
30%, not to
exceed $250
20%, not to
exceed $250
Emergency ambulance
services (per trip)
$100 $100 $100 $100 $100
CT/PET/MRI (per procedure) $50 $50 $50 $50 $100
Lab/X-ray (per encounter) $10 $10 $10 $10 $10
Durable medical
equipment
20% 20% 20%
20% 50%
Fertility services 50% 50% 50% 50% 50%
Prenatal care and
well-baby visits
No charge No charge No charge No charge
No charge
Optical hardware Not covered Not covered Not covered
$150 hardware
allowance/24 months
Not covered
Prosthetics and orthotics No charge No charge No charge No charge No charge
1. Traditional HMO — Pay a simple copay for most covered services. 2. Telehealth — Telehealth services include scheduled phone and video visits,
as well as email consultations, when appropriate and available. These features are available when you get care from Kaiser Permanente providers.
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Overvi ew HMO DHMO CDHC POS/PPO
Compare plans
Plans selected:
Complete Suite category
HMO
HMO Low
1
HMO Low
1
HMO Low
1
HMO Low
1
HMO Low
1
NCAL/SCAL plan ID 9957/9958 9959/9960 9967/9969 9973/9974 9979/9980
Plan deductible
(individual/family)
None None None None None
Out-of-pocket maximum
(individual/family)
$3,000/$6,000 $3,000/$6,000 $3,000/$6,000 $3,000/$6,000 $3,500/$7,000
Telehealth
2
No charge No charge No charge No charge No charge
Preventive care No charge No charge No charge No charge No charge
Primary and specialty
care visit
$30 $20 $30 $30 $30/$50
Hospital inpatient
(per admission)
$250 per day
up to 3 days
$500 per day
up to 3 days
$500 per day
up to 3 days
$500 per day $500 per day
Outpatient surgery
(per procedure)
$125 $250 $250 $250 $250
Emergency care $100 $150 $150 $150 $150
Prescription drugs
Generic $10 $15 $15 $15 $15
Brand $30 $35 $35 $35 $35
Specialty
20%, not to
exceed $250
30%, not to
exceed $250
30%, not to
exceed $250
30%, not to
exceed $250
30%, not to
exceed $250
Emergency ambulance
services (per trip)
$100 $150 $150 $150 $150
CT/PET/MRI (per procedure) $100 $100 $100 $100 $100
Lab/X-ray (per encounter) $10 $10 $10 $10 $10
Durable medical
equipment
50%
50% 50% 50% 50%
Fertility services 50% 50% 50% 50% 50%
Prenatal care and
well-baby visits
No charge No charge No charge No charge No charge
Optical hardware Not covered Not covered Not covered Not covered Not covered
Prosthetics and orthotics No charge No charge No charge No charge No charge
1. Traditional HMO — Pay a simple copay for most covered services. 2. Telehealth — Telehealth services include scheduled phone and video visits,
as well as email consultations, when appropriate and available. These features are available when you get care from Kaiser Permanente providers.
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Overvi ew HMO DHMO CDHC POS/PPO
Compare plans
Plans selected:
Complete Suite category
HMO
HMO Low
1
HMO Low
1
HMO Low (Coinsurance)
2
NCAL/SCAL plan ID 9977/9978 9942/9943 13058/13059
Plan deductible
(individual/family)
None None None
Out-of-pocket maximum
(individual/family)
$3,000/$6,000 $3,500/$7,000 $4,000/$8,000
Telehealth
3
No charge No charge No charge
Preventive care No charge No charge No charge
Primary and specialty
care visit
$40 $40/$50 $40/$50
Hospital inpatient
(per admission)
$500 per day $500 per day 30%
Outpatient surgery
(per procedure)
$250 $250 30%
Emergency care $150 $150 30%
Prescription drugs
Generic $15 $15 $15
Brand $35 $35 $35
Specialty 30%, not to exceed $250 30%, not to exceed $250 30%, not to exceed $250
Emergency ambulance
services (per trip)
$150 $150 $150
CT/PET/MRI (per procedure) $100 $100 30%, not to exceed $150
Lab/X-ray (per encounter) $10 $10 $15
Durable medical
equipment
50% 50% 50%
Fertility services 50% 50% 50%
Prenatal care and
well-baby visits
No charge No charge No charge
Optical hardware Not covered Not covered Not covered
Prosthetics and orthotics No charge No charge No charge
1. Traditional HMO — Pay a simple copay for most covered services. 2. Coinsurance HMO — Pay office visit copays; coinsurance for most other services.
3. Telehealth — Telehealth services include scheduled phone and video visits, as well as email consultations, when appropriate and available. These
features are available when you get care from Kaiser Permanente providers.
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Overvi ew HMO DHMO CDHC POS/PPO
Compare plans
Plans selected:
Complete Suite category
DHMO
Deductible HMO HO
1
Deductible HMO HO
1
Deductible HMO HO
1
Deductible HMO HO
1
NCAL/SCAL plan ID 8776/8777 8780/8781 8782/8783 13872/13873
Plan deductible
(individual/family)
$250/$500 $500/$1,000 $750/$1,500 $750/$1,500
Out-of-pocket maximum
(individual/family)
$3,000/$6,000 $3,000/$6,000 $3,000/$6,000 $3,000/$6,000
Telehealth
2
No charge No charge No charge No charge
Preventive care No charge No charge No charge No charge
Primary and specialty
care visit
$10 $20 $25 $25
Hospital inpatient
(per admission)
10% after deductible 10% after deductible 20% after deductible 20% after deductible
Outpatient surgery
(per procedure)
10% after deductible 10% after deductible 20% after deductible 20% after deductible
Emergency care 10% after deductible 10% after deductible 20% after deductible 20% after deductible
Prescription drugs
Generic $10 $10 $10 $10
Brand $30 $30 $30 $30
Specialty
20%, not to
exceed $250
20%, not to
exceed $250
20%, not to
exceed $250
20%, not to
exceed $250
Emergency ambulance
services (per trip)
$150 $150 $150 $150
CT/PET/MRI (per procedure)
10%, not to
exceed $150
10%, not to
exceed $150
20%, not to
exceed $150
20%, not to
exceed $150
Lab/X-ray (per encounter) $10 $10 $10 $10
Durable medical
equipment
20% 20% 20% 20%
Fertility services 50% 50% 50% 50%
Prenatal care and
well-baby visits
No charge No charge No charge No charge
Optical hardware Not covered Not covered
Not covered
$150 hardware
allowance/24 mo.
Prosthetics and orthotics No charge No charge No charge No charge
1. Deductible HMO HO — Most services are covered at a copay or coinsurance. A deductible applies to hospital services, such as inpatient hospital,
outpatient surgery, and emergency room services. 2. Telehealth — Telehealth services include scheduled phone and video visits, as well as email
consultations, when appropriate and available. These features are available when you get care from Kaiser Permanente providers.
14
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Overvi ew HMO DHMO CDHC POS/PPO
Compare plans
Plans selected:
Complete Suite category
DHMO
Deductible HMO HO
1
Deductible HMO HO
1
Deductible HMO HO
1
Deductible HMO HO
1
Deductible HMO HO
1
NCAL/SCAL plan ID 8784/8785 10690/10691 8790/8791 10692/10693 13046/13047
Plan deductible
(individual/family)
$1,000/$2,000 $1,000/$2,000 $1,500/$3,000 $1,500/$3,000 $2,000/$4,000
Out-of-pocket maximum
(individual/family)
$3,000/$6,000 $3,000/$6,000 $4,000/$8,000 $4,000/$8,000 $4,500/$9,000
Telehealth
2
No charge No charge No charge No charge No charge
Preventive care No charge No charge No charge No charge No charge
Primary and specialty
care visit
$20 $20 $20 $20 $20
Hospital inpatient
(per admission)
20% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible
Outpatient surgery
(per procedure)
20% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible
Emergency care 20% after deductible 20% after deductible 20% after deductible 20% after deductible 20% after deductible
Prescription drugs
Generic $10 $10 $10 $10 $10
Brand $30 $30 $30 $30 $30
Specialty
20%, not to
exceed $250
20%, not to
exceed $250
20%, not to
exceed $250
20%, not to
exceed $250
20%, not to
exceed $250
Emergency ambulance
services (per trip)
$150 $150 $150 $150 $150
CT/PET/MRI (per procedure)
20%, not to
exceed $150
20%, not to
exceed $150
20%, not to
exceed $150
20%, not to
exceed $150
20%, not to
exceed $150
Lab/X-ray (per encounter) $10 $10 $10 $10 $10
Durable medical
equipment
20% 20% 20% 20% 20%
Fertility services 50% 50% 50% 50% 50%
Prenatal care and
well-baby visits
No charge No charge No charge No charge No charge
Optical hardware Not covered
$150 hardware
allowance/24 months
Not covered
$130 hardware
allowance/24 months
Not covered
Prosthetics and orthotics No charge No charge No charge No charge No charge
1. Deductible HMO HO — Most services are covered at a copay or coinsurance. A deductible applies to hospital services, such as inpatient hospital,
outpatient surgery, and emergency room services. 2. Telehealth — Telehealth services include scheduled phone and video visits, as well as email
consultations, when appropriate and available. These features are available when you get care from Kaiser Permanente providers.
15
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Overvi ew HMO DHMO CDHC POS/PPO
Compare plans
Plans selected:
Complete Suite category
DHMO
Deductible HMO HO
1
Deductible HMO HO
1
Deductible HMO HO
1
NCAL/SCAL plan ID 8794/8795 8792/8793 10208/10209
Plan deductible
(individual/family)
$2,500/$5,000 $1,500/$3,000 $3,000/$6,000
Out-of-pocket maximum
(individual/family)
$5,000/$10,000 $4,000/$8,000 $6,000/$12,000
Telehealth
2
No charge No charge No charge
Preventive care No charge No charge No charge
Primary and specialty
care visit
$20 $40 $40
Hospital inpatient
(per admission)
20% after deductible 30% after deductible 30% after deductible
Outpatient surgery
(per procedure)
20% after deductible 30% after deductible 30% after deductible
Emergency care 20% after deductible 30% after deductible 30% after deductible
Prescription drugs
Generic $10 $10 $10
Brand $30 $30 $30
Specialty 20%, not to exceed $250 20%, not to exceed $250 20%, not to exceed $250
Emergency ambulance
services (per trip)
$150 $150 $150
CT/PET/MRI (per procedure) 20%, not to exceed $150 30%, not to exceed $150 30%, not to exceed $150
Lab/X-ray (per encounter) $10 $15 $15
Durable medical equipment 20% 20% 20%
Fertility services 50% 50% 50%
Prenatal care and
well-baby visits
No charge No charge No charge
Optical hardware Not covered Not covered Not covered
Prosthetics and orthotics No charge No charge No charge
1. Deductible HMO HO — Most services are covered at a copay or coinsurance. A deductible applies to hospital services, such as inpatient hospital,
outpatient surgery, and emergency room services. 2. Telehealth — Telehealth services include scheduled phone and video visits, as well as email
consultations, when appropriate and available. These features are available when you get care from Kaiser Permanente providers.
16
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Overvi ew HMO DHMO CDHC POS/PPO
Compare plans
Plans selected:
Complete Suite category
DHMO
Deductible HMO XD
1
Deductible HMO XD
1
Deductible HMO XD
1
Deductible HMO XD
1
NCAL/SCAL plan ID 8796/8797 8800/8801 8808/8809 8804/8805
Plan deductible
(individual/family)
$250/$500 $500/$1,000 $750/$1,500 $1,000/$2,000
Out-of-pocket maximum
(individual/family)
$2,500/$5,000 $3,000/$6,000 $3,000/$6,000 $3,000/$6,000
Telehealth
2
No charge No charge No charge No charge
Preventive care No charge No charge No charge No charge
Primary and specialty
care visit
$10 $20 $25 $20
Hospital inpatient
(per admission)
10% after deductible 20% after deductible 20% after deductible 20% after deductible
Outpatient surgery
(per procedure)
10% after deductible 20% after deductible 20% after deductible 20% after deductible
Emergency care 10% after deductible 20% after deductible 20% after deductible 20% after deductible
Prescription drugs
Generic $10 $10 $10 $10
Brand $30 $30 $30 $30
Specialty 20%, not to exceed $250 20%, not to exceed $250 20%, not to exceed $250 20%, not to exceed $250
Emergency ambulance
services (per trip)
$150 after deductible $150 after deductible $150 after deductible $150 after deductible
CT/PET/MRI (per procedure)
10%, not to exceed
$150 after deductible
20%, not to exceed
$150 after deductible
20%, not to exceed
$150 after deductible
20%, not to exceed
$150 after deductible
Lab/X-ray (per encounter) $10 after deductible $10 after deductible $10 after deductible $10 after deductible
Durable medical
equipment
20% 20% 20% 20%
Fertility services 50% 50% 50% 50%
Prenatal care and
well-baby visits
No charge No charge No charge No charge
Optical hardware Not covered Not covered Not covered Not covered
Prosthetics and orthotics No charge No charge No charge No charge
1. Deductible HMO XD — Provider office visits and pharmacy are covered at a copay or coinsurance. A deductible applies to most other services.
2. Telehealth — Telehealth services include scheduled phone and video visits, as well as email consultations, when appropriate and available. These
features are available when you get care from Kaiser Permanente providers.
17
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Overvi ew HMO DHMO CDHC POS/PPO
Compare plans
Plans selected:
Complete Suite category
DHMO
Deductible HMO XD
1
Deductible HMO XD
1
Deductible HMO XD
1
Deductible HMO XD
1
NCAL/SCAL plan ID 8810/8811 8814/8815 8818/8819 8816/8817
Plan deductible
(individual/family)
$1,000/$2,000 $1,500/$3,000 $2,000/$4,000 $1,500/$3,000
Out-of-pocket maximum
(individual/family)
$3,000/$6,000 $4,000/$8,000 $4,000/$8,000 $4,000/$8,000
Telehealth
2
No charge No charge No charge No charge
Preventive care No charge No charge No charge No charge
Primary and specialty
care visit
$30 $20 $20 $40
Hospital inpatient
(per admission)
30% after deductible 20% after deductible 20% after deductible 30% after deductible
Outpatient surgery
(per procedure)
30% after deductible 20% after deductible 20% after deductible 30% after deductible
Emergency care 30% after deductible 20% after deductible 20% after deductible 30% after deductible
Prescription drugs
Generic $10 $10 $10 $10
Brand $30 $30 $30 $30
Specialty 20%, not to exceed $250 20%, not to exceed $250 20%, not to exceed $250 20%, not to exceed $250
Emergency ambulance
services (per trip)
$150 after deductible $150 after deductible $150 after deductible $150 after deductible
CT/PET/MRI (per procedure)
30%, not to exceed
$150 after deductible
20%, not to exceed
$150 after deductible
20%, not to exceed
$150 after deductible
30%, not to exceed
$150 after deductible
Lab/X-ray (per encounter) $10 after deductible $10 after deductible $10 after deductible $15 after deductible
Durable medical
equipment
20% 20% 20% 20%
Fertility services 50% 50% 50% 50%
Prenatal care and
well-baby visits
No charge No charge No charge No charge
Optical hardware Not covered Not covered Not covered Not covered
Prosthetics and orthotics No charge No charge No charge No charge
1. Deductible HMO XD — Provider office visits and pharmacy are covered at a copay or coinsurance. A deductible applies to most other services.
2. Telehealth — Telehealth services include scheduled phone and video visits, as well as email consultations, when appropriate and available. These
features are available when you get care from Kaiser Permanente providers.
18
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Overvi ew HMO DHMO CDHC POS/PPO
Compare plans
Plans selected:
Complete Suite category
DHMO
Deductible HMO XD
1
Deductible HMO XD
1
Deductible HMO XD
1
Deductible HMO XD
1
NCAL/SCAL plan ID 8820/8821 8822/8823
13864/13865
(formerly 8824/8825)
13868/13869
(formerly 11904/11905)
Plan deductible
(individual/family)
$2,500/$5,000 $3,000/$6,000 $3,500/$7,000 $4,000/$8,000
Out-of-pocket maximum
(individual/family)
$5,000/$10,000 $6,000/$12,000 $6,500/$13,000 $7,000/$14,000
Telehealth
2
No charge No charge No charge No charge
Preventive care No charge No charge No charge No charge
Primary and specialty
care visit
$40 $40 $40 $40/$50
Hospital inpatient
(per admission)
30% after deductible 30% after deductible 30% after deductible 30% after deductible
Outpatient surgery
(per procedure)
30% after deductible 30% after deductible 30% after deductible 30% after deductible
Emergency care 30% after deductible 30% after deductible 30% after deductible 30% after deductible
Prescription drugs
Generic $10 $10 $10 $15
Brand $30 $30 $30 $40
Specialty 20%, not to exceed $250 20%, not to exceed $250 20%, not to exceed $250 30%, not to exceed $250
Emergency ambulance
services (per trip)
$150 after deductible $150 after deductible $150 after deductible $150 after deductible
CT/PET/MRI (per procedure)
30%, not to exceed
$150 after deductible
30%, not to exceed
$150 after deductible
30%, not to exceed $150
after deductible
30%, not to exceed $150
after deductible
Lab/X-ray (per encounter) $15 after deductible $15 after deductible $15 after deductible $15 after deductible
Durable medical
equipment
20% 20% 20% 30%
Fertility services 50% 50% 50% 50%
Prenatal care and
well-baby visits
No charge No charge No charge No charge
Optical hardware Not covered Not covered Not covered Not covered
Prosthetics and orthotics No charge No charge No charge
No charge
1. Deductible HMO XD — Provider office visits and pharmacy are covered at a copay or coinsurance. A deductible applies to most other services.
2. Telehealth — Telehealth services include scheduled phone and video visits, as well as email consultations, when appropriate and available. These
features are available when you get care from Kaiser Permanente providers.
19
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Overvi ew HMO DHMO CDHC POS/PPO
Compare plans
Plans selected:
Complete Suite category
DHMO
Virtual Complete Virtual Complete Virtual Complete Virtual Complete
Virtual Complete
NCAL/SCAL plan ID 13770/13771 13774/13775 13778/13779 13782/13783 13786/13787
Plan deductible
(individual/family)
$2,000/$4,000 $2,500/$5,000 $3,000/$6,000 $4,000/$8,000 $5,000/$10,000
Out-of-pocket maximum
(individual/family)
$5,000/$10,000 $5,500/$11,000 $6,000/$12,000 $7,000/$14,000 $8,000/$16,000
Telehealth
1
No charge No charge No charge No charge No charge
Preventive care No charge No charge No charge No charge No charge
Primary and specialty
care visit
$30 after deductible
2
$40 after deductible
2
$40 after deductible
2
$50 after deductible
2
$50 after deductible
2
Hospital inpatient
(per admission)
20% after deductible 20% after deductible 30% after deductible 30% after deductible 40% after deductible
Outpatient surgery
(per procedure)
20% after deductible 20% after deductible 30% after deductible 30% after deductible 40% after deductible
Emergency care 20% after deductible 20% after deductible 30% after deductible 30% after deductible 40% after deductible
Prescription drugs
Generic $15 $15 $15 $15 $15
Brand $30 after deductible $40 after deductible $40 after deductible $50 after deductible $50 after deductible
Specialty
20% after
deductible, not to
exceed $250
20% after
deductible, not to
exceed $250
30% after
deductible, not to
exceed $250
30% after
deductible, not to
exceed $250
40% after
deductible, not to
exceed $250
Emergency ambulance
services (per trip)
20% after
deductible
20% after
deductible
30% after
deductible
30% after
deductible
40% after
deductible
CT/PET/MRI (per procedure)
20% after
deductible
20% after
deductible
30% after
deductible
30% after
deductible
40% after
deductible
Lab/X-ray (per encounter)
Lab: $15 no ded
X-Ray: 20% after
deductible
Lab: $15 no ded
X-Ray: 20% after
deductible
Lab: $15 no ded
X-Ray: 30% after
deductible
Lab: $15 no ded
X-Ray: 30% after
deductible
Lab: $15 no ded
X-Ray: 40% after
deductible
Durable medical
equipment
20% 20% 30% 30% 40%
Fertility services 50% 50% 50% 50% 50%
Prenatal care and
well-baby visits
No charge No charge No charge No charge No charge
Optical hardware Not covered Not covered Not covered Not covered Not covered
Prosthetics and orthotics No charge No charge No charge No charge No charge
1. Telehealth — Telehealth services include scheduled phone and video visits, as well as email consultations, when appropriate and available. These
features are available when you get care from Kaiser Permanente providers. 2. Plan deductible doesn’t apply to the first 3 visits combined for
primary care, urgent care, mental health, and substance use disorder treatment.
20
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Overvi ew HMO DHMO CDHC POS/PPO
Compare plans
Plans selected:
Complete Suite category
DHMO
Deductible HMO CDO
1
Deductible HMO CDO
1
NCAL/SCAL plan ID
13860/13861
(formerly 9151/9163)
13858/13859
(formerly 9150/9161)
Plan deductible
(individual/family)
$5,000/$10,000 $5,500/$11,000
Out-of-pocket maximum
(individual/family)
$7,000/$14,000 $7,500/$15,000
Telehealth
2
No charge No charge
Preventive care No charge No charge
Primary and specialty care visit $50 after deductible
3
$50 after deductible
3
Hospital inpatient
(per admission)
30% after deductible 40% after deductible
Outpatient surgery
(per procedure)
30% after deductible 40% after deductible
Emergency care 30% after deductible 40% after deductible
Prescription drugs
Generic $15 after plan deductible
4
$15 after plan deductible
4
Brand $50 after plan deductible 40%, not to exceed $100 after plan deductible
Specialty 30%, not to exceed $250 after plan deductible 40%, not to exceed $250 after plan deductible
Emergency ambulance
services (per trip)
30% after deductible 40% after deductible
CT/PET/MRI (per procedure) 30% after deductible 40% after deductible
Lab/X-ray (per encounter) 30% after deductible 40% after deductible
Durable medical equipment 30% 40%
Fertility services Not covered Not covered
Prenatal care and
well-baby visits
No charge No charge
Optical hardware Not covered Not covered
Prosthetics and orthotics No charge No charge
1. Deductible HMO CDO — Preventive care is covered at no cost. A deductible applies to most services, including pharmacy. 2. Telehealth —
Telehealth services include scheduled phone and video visits, as well as email consultations, when appropriate and available. These features are
available when you get care from Kaiser Permanente providers. 3. Plan deductible doesn’t apply to the first 3 visits combined for primary care,
urgent care, mental health, and substance use disorder treatment. 4. Supplemental preventive drugs available at a lower cost share and before
plan deductible. All other prescriptions are subject to plan deductible.
21
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Overvi ew HMO DHMO CDHC POS/PPO
Compare plans
Plans selected:
Complete Suite category
CDHC
HSA-qualified HDHP HMO
1
HSA-qualified HDHP HMO
1
HSA-qualified HDHP HMO
1
NCAL/SCAL plan ID 12189/12191 12195/12196 12168/12167
Plan deductible
Self-only $1,400 $1,500 $2,800
Family member/family $2,800/$2,800 $2,800/$3,000 $2,800/$5,600
Out-of-pocket maximum
Self-only $3,000 $3,000 $2,800
Family member/family $3,000/$6,000 $3,000/$6,000 $2,800/$5,600
Telehealth
2
$0 after plan deductible $0 after plan deductible $0 after plan deductible
Preventive care No charge No charge No charge
Primary and specialty
care visit
$20 after plan deductible 10% after plan deductible $0 after plan deductible
Hospital inpatient
(per admission)
$250 after plan deductible 10% after plan deductible $0 after plan deductible
Outpatient surgery
(per procedure)
$150 after plan deductible 10% after plan deductible $0 after plan deductible
Emergency care $100 after plan deductible 10% after plan deductible $0 after plan deductible
Prescription drugs
Generic $10 after plan deductible $10 after plan deductible $0 after plan deductible
Brand $30 after plan deductible $30 after plan deductible $0 after plan deductible
Specialty
20%, not to exceed $250 after
plan deductible
20%, not to exceed $250 after
plan deductible
$0 after plan deductible
Emergency ambulance services
(per trip)
$100 after plan deductible 10% after plan deductible $0 per trip after plan deductible
CT/PET/MRI (per procedure) $150 after plan deductible 10% after plan deductible $0 after plan deductible
Lab/X-ray (per encounter) $10 after plan deductible 10% after plan deductible $0 after plan deductible
Durable medical
equipment
20% after plan deductible 10% after plan deductible $0 after plan deductible
Fertility services Not covered Not covered Not covered
Prenatal care and
well-baby visits
No charge No charge No charge
Optical hardware Not covered Not covered Not covered
Prosthetics and orthotics No charge after plan deductible No charge after plan deductible No charge after plan deductible
1. HSA-qualified HDHP HMO — All services, except preventive services, are subject to a deductible. 2. Telehealth — Telehealth services include
scheduled phone and video visits, as well as email consultations, when appropriate and available. These features are available when you get care
from Kaiser Permanente providers.
22
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Overview HMO DHMO CDHC POS/PPO
Compare plans
Plans selected:
Complete Suite category
CDHC
HSA-qualified HDHP HMO
1
HSA-qualified HDHP HMO
1
HSA-qualified HDHP HMO
1
NCAL/SCAL plan ID 12190/12193 11908/11909 12187/12188
Plan deductible
Self-only $2,000 $2,500 $2,800
Family member/family $2,800/$4,000 $2,800/$5,000 $2,800/$5,600
Out-of-pocket maximum
Self-only $3,500 $4,500 $5,250
Family member/family $3,500/$7,000 $4,500/$9,000 $5,250/$10,500
Telehealth
2
$0 after plan deductible $0 after plan deductible $0 after plan deductible
Preventive care No charge No charge No charge
Primary and specialty
care visit
$30 after plan deductible $30 after plan deductible $30 after plan deductible
Hospital inpatient
(per admission)
$250 after plan deductible $250 after plan deductible 30% after plan deductible
Outpatient surgery
(per procedure)
$150 after plan deductible $150 after plan deductible 30% after plan deductible
Emergency care $100 after plan deductible $100 after plan deductible 30% after plan deductible
Prescription drugs
Generic $10 after plan deductible $10 after plan deductible $15 after plan deductible
Brand $30 after plan deductible $30 after plan deductible $30 after plan deductible
Specialty
20%, not to exceed $250 after
plan deductible
20%, not to exceed $250
after plan deductible
20%, not to exceed $250
after plan deductible
Emergency ambulance services
(per trip)
$100 after plan deductible $100 per trip after plan deductible $100 after plan deductible
CT/PET/MRI (per procedure) $150 after plan deductible $150 after plan deductible
30%, not to exceed
$150 after plan deductible
Lab/X-ray (per encounter) $10 after plan deductible $10 after plan deductible $10 after plan deductible
Durable medical
equipment
20% after plan deductible 20% after plan deductible 20% after plan deductible
Fertility services Not covered Not covered Not covered
Prenatal care and
well-baby visits
No charge No charge No charge
Optical hardware Not covered Not covered Not covered
Prosthetics and orthotics No charge after plan deductible No charge after plan deductible No charge after plan deductible
1. HSA-qualified HDHP HMO — All services, except preventive services, are subject to a deductible. 2. Telehealth — Telehealth services include
scheduled phone and video visits, as well as email consultations, when appropriate and available. These features are available when you get care
from Kaiser Permanente providers.
23
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Overview HMO DHMO CDHC POS/PPO
Compare plans
Plans selected:
Complete Suite category
CDHC
HSA-qualified
HDHP HMO
1
HSA-qualified
HDHP HMO
1
HSA-qualified
HDHP HMO
1
HSA-qualified
HDHP HMO
1
NCAL/SCAL plan ID 10426/10427
13877/13878
(formerly 8122/8125)
13854/13855
(formerly 8126/8127)
13850/13851
(formerly 10160/10161)
Plan deductible
Self-only $3,500 $4,500 $4,500 $5,500
Family member/family $3,500/$7,000 $4,500/$9,000 $4,500/$9,000 $5,500/$11,000
Out-of-pocket maximum
Self-only $6,000 $6,250 $6,500 $7,000
Family member/family $6,000/$12,000 $6,250/$12,500 $6,500/$13,000 $7,000/$14,000
Telehealth
2
$0 after plan deductible $0 after plan deductible $0 after plan deductible $0 after plan deductible
Preventive care No charge No charge No charge No charge
Primary and specialty
care visit
$30 after plan deductible
$40 after plan
deductible
40% after plan
deductible
$50 after plan
deductible
Hospital inpatient
(per admission)
30% after plan
deductible
40% after plan
deductible
40% after plan
deductible
40% after plan
deductible
Outpatient surgery
(per procedure)
30% after plan
deductible
40% after plan
deductible
40% after plan
deductible
40% after plan
deductible
Emergency care
30% after plan
deductible
$250 after plan
deductible
40% after plan
deductible
40% after plan
deductible
Prescription drugs
Generic
$15 after plan
deductible
$15 after plan
deductible
30% after plan deductible,
not to exceed $50
$15 after plan
deductible
3
Brand
$35 after plan
deductible
$35 after plan
deductible
40% after plan deductible,
not to exceed $100
40%, not to exceed $100
after plan deductible
Specialty
30%, not to exceed $250
after plan deductible
30%, not to exceed $250
after plan deductible
40%, not to exceed $250
after plan deductible
40%, not to exceed $250
after plan deductible
Emergency ambulance services
(per trip)
30% after plan
deductible
40% after plan
deductible
40% after plan
deductible
40% after plan
deductible
CT/PET/MRI (per procedure)
30% after plan
deductible
40%, not to exceed $150
after plan deductible
40% after plan
deductible
40% after plan
deductible
Lab/X-ray (per encounter)
$10 after plan
deductible
40% after plan
deductible
40% after plan
deductible
40% after plan
deductible
Durable medical
equipment
30% after plan
deductible
40% after plan
deductible
40% after plan
deductible
40% after plan
deductible
Fertility services Not covered Not covered Not covered Not covered
Prenatal care and
well-baby visits
No charge No charge No charge No charge
Optical hardware Not covered Not covered Not covered Not covered
Prosthetics and orthotics
No charge after plan
deductible
No charge after plan
deductible
No charge after plan
deductible
No charge after plan
deductible
1. HSA-qualified HDHP HMO — All services, except preventive services, are subject to a deductible. 2. Telehealth — Telehealth services include
scheduled phone and video visits, as well as email consultations, when appropriate and available. These features are available when you get care
from Kaiser Permanente providers. 3. Supplemental preventive drugs available at a lower cost share and before plan deductible.
24
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Overvi ew HMO DHMO CDHC POS/PPO
Compare plans
Plans selected:
Complete Suite category
CDHC
DHMO with HRA
1
DHMO with HRA
1
DHMO with HRA
1
DHMO with HRA
1
NCAL/SCAL plan ID 8759/8760 8761/8762 8763/8764 8765/8766
Plan deductible
(individual/family)
$1,000/$2,000 $1,500/$3,000 $2,000/$4,000 $2,500/$5,000
Out-of-pocket maximum
(individual/family)
$2,000/$4,000 $3,000/$6,000 $4,000/$8,000 $5,000/$10,000
Telehealth
2
No charge No charge No charge No charge
Preventive care No charge No charge No charge No charge
Primary and specialty
care visit
$20 after plan deductible $20 after plan deductible $20 after plan deductible $20 after plan deductible
Hospital inpatient
(per admission)
20% after plan deductible 20% after plan deductible 20% after plan deductible 20% after plan deductible
Outpatient surgery
(per procedure)
20% after plan deductible 20% after plan deductible 20% after plan deductible 20% after plan deductible
Emergency care 20% after plan deductible 20% after plan deductible 20% after plan deductible 20% after plan deductible
Prescription drugs
Generic $10 $10 $10 $10
Brand $30 $30 $30 $30
Specialty 20%, not to exceed $250 20%, not to exceed $250 20%, not to exceed $250 20%, not to exceed $250
Emergency ambulance
services (per trip)
$150 after plan
deductible
$150 after plan
deductible
$150 after plan
deductible
$150 after plan
deductible
CT/PET/MRI (per procedure)
20%, not to exceed $150
after plan deductible
20%, not to exceed $150
after plan deductible
20%, not to exceed $150
after plan deductible
20%, not to exceed $150
after plan deductible
Lab/X-ray (per encounter) $10 after plan deductible $10 after plan deductible $10 after plan deductible $10 after plan deductible
Durable medical
equipment
20% 20% 20% 20%
Fertility services 50% 50% 50% 50%
Prenatal care and
well-baby visits
No charge No charge No charge No charge
Optical hardware Not covered Not covered Not covered Not covered
Prosthetics and orthotics No charge No charge No charge No charge
1. Deductible HMO — Plans with HRA have XP accumulation, meaning pharmacy is covered at a copay or coinsurance. A deductible applies to most
other services. 2. Telehealth — Telehealth services include scheduled phone and video visits, as well as email consultations, when appropriate and
available. These features are available when you get care from Kaiser Permanente providers.
25
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Overvi ew HMO DHMO CDHC POS/PPO
Compare plans
Plans selected:
Complete Suite category
CDHC
DHMO with HRA
1
DHMO with HRA
1
DHMO with HRA
1
NCAL/SCAL plan ID 7823/7824 13050/13051
13822/13823
(formerly 13054/13055)
Plan deductible
(individual/family)
$3,000/$6,000 $3,500/$7,000 $4,000/$8,000
Out-of-pocket maximum
(individual/family)
$6,000/$12,000 $6,500/$13,000 $7,000/$14,000
Telehealth
2
No charge No charge No charge
Preventive care No charge No charge No charge
Primary and specialty
care visit
30% after plan deductible 30% after plan deductible 30% after plan deductible
Hospital inpatient
(per admission)
30% after plan deductible 30% after plan deductible 30% after plan deductible
Outpatient surgery
(per procedure)
30% after plan deductible 30% after plan deductible 30% after plan deductible
Emergency care 30% after plan deductible 30% after plan deductible 30% after plan deductible
Prescription drugs
Generic 30%, not to exceed $50 30%, not to exceed $50 30%, not to exceed $50
Brand 30%, not to exceed $100 30%, not to exceed $100 30%, not to exceed $100
Specialty 30%, not to exceed $250 30%, not to exceed $250 30%, not to exceed $250
Emergency ambulance services
(per trip)
30% after plan deductible 30% after plan deductible 30% after plan deductible
CT/PET/MRI
(per procedure)
30% after plan deductible 30% after plan deductible 30% after plan deductible
Lab/X-ray (per encounter) 30% after plan deductible 30% after plan deductible 30% after plan deductible
Durable medical equipment 30% 30% 30%
Fertility services 50% 50% 50%
Prenatal care and
well-baby visits
No charge No charge No charge
Optical hardware Not covered Not covered Not covered
Prosthetics and orthotics No charge No charge No charge
1. Deductible HMO — Plans with HRA have XP accumulation, meaning pharmacy is covered at a copay or coinsurance. A deductible applies to most
other services. 2. Telehealth — Telehealth services include scheduled phone and video visits, as well as email consultations, when appropriate and
available. These features are available when you get care from Kaiser Permanente providers.
26
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Overvi ew HMO DHMO CDHC POS/PPO
Compare plans
Plans selected:
Complete Suite category
POS
1
NCAL/SCAL plan ID 13886/13887
Tier HMO Tier Participating Provider Tier Nonparticipating Provider Tier
Plan deductible
(individual/family)
$0/$0 $500/$1,000 $1,000/$2,000
Out-of-pocket maximum
(individual/family)
$1,500/$3,000 $3,000/$6,000 $6,000/$12,000
Telehealth
2
No charge $35 40% after plan deductible
Preventive care No charge No charge 40%
Primary and specialty
care visit
$20 $35 40% after plan deductible
Hospital inpatient
(per admission)
$250 $250 + 20% after plan deductible $500 + 40% after plan deductible
Outpatient surgery
(per procedure)
$100 20% after plan deductible 40% after plan deductible
Emergency care $150 Covered under the HMO tier Covered under the HMO tier
Prescription drugs
Generic $10 $20 preferred, $50 nonpreferred Not covered
Brand $30 $40 preferred, $50 nonpreferred Not covered
Specialty 20%, not to exceed $250 30%, not to exceed $250 Not covered
Emergency ambulance
services (per trip)
$150 Covered under the HMO tier Covered under the HMO tier
CT/PET/MRI (per procedure) No charge $35 40% after plan deductible
Lab/X-ray (per encounter) No charge $35 40% after plan deductible
Durable medical equipment 30% 30% after plan deductible 50% after plan deductible
Fertility services $20 20% 40%
Prenatal care and
well-baby visits
No charge No charge 40%
Optical hardware Not covered Not covered Not covered
Prosthetics and orthotics No charge 20% after plan deductible 40% after plan deductible
1. The HMO tier of the point-of-service (POS) plan is underwritten by Kaiser Foundation Health Plan, Inc. (KFHP), while the participating provider
and nonparticipating provider tiers of the POS plan are underwritten by Kaiser Permanente Insurance Company (KPIC). KPIC is a subsidiary of KFHP.
2. Telehealth — Telehealth services include scheduled phone and video visits, as well as email consultations, when appropriate and available.
27
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Overvi ew HMO DHMO CDHC POS/PPO
Compare plans
Plans selected:
Complete Suite category
POS
1
NCAL/SCAL plan ID 13890/13891
Tier HMO Tier Participating Provider Tier Nonparticipating Provider Tier
Plan deductible
(individual/family)
$0/$0 $1,000/$2,000 $2,000/$4,000
Out-of-pocket maximum
(individual/family)
$2,000/$4,000 $3,500/$7,000 $7,000/$14,000
Telehealth
2
No charge $50 40% after plan deductible
Preventive care No charge No charge 40%
Primary and specialty
care visit
$25 $50 40% after plan deductible
Hospital inpatient
(per admission)
$250 $250 + 20% after plan deductible $500 + 40% after plan deductible
Outpatient surgery
(per procedure)
$100 20% after plan deductible 40% after plan deductible
Emergency care $150 Covered under the HMO tier Covered under the HMO tier
Prescription drugs
Generic $10 $20 preferred, $50 nonpreferred Not covered
Brand $30 $40 preferred, $50 nonpreferred Not covered
Specialty 20%, not to exceed $250 30%, not to exceed $250 Not covered
Emergency ambulance
services (per trip)
$150 Covered under the HMO tier Covered under the HMO tier
CT/PET/MRI (per procedure) $10 $50 40% after plan deductible
Lab/X-ray (per encounter) $10 $50 40% after plan deductible
Durable medical equipment 30% 30% after plan deductible 50% after plan deductible
Fertility services $25 20% 40%
Prenatal care and
well-baby visits
No charge No charge 40%
Optical hardware Not covered Not covered Not covered
Prosthetics and orthotics No charge 20% after plan deductible 40% after plan deductible
1. The HMO tier of the point-of-service (POS) plan is underwritten by Kaiser Foundation Health Plan, Inc. (KFHP), while the participating provider
and nonparticipating provider tiers of the POS plan are underwritten by Kaiser Permanente Insurance Company (KPIC). KPIC is a subsidiary of KFHP.
2. Telehealth — Telehealth services include scheduled phone and video visits, as well as email consultations, when appropriate and available.
28
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Overvi ew HMO DHMO CDHC POS/PPO
Compare plans
Plans selected:
Complete Suite category
POS
1
NCAL/SCAL plan ID 13894/13895
Tier HMO Tier Participating Provider Tier Nonparticipating Provider Tier
Plan deductible
(individual/family)
$0/$0 $1,500/$3,000 $3,000/$6,000
Out-of-pocket maximum
(individual/family)
$2,500/$5,000 $4,500/$9,000 $9,000/$18,000
Telehealth
2
No charge 20% after plan deductible 50% after plan deductible
Preventive care No charge No charge 50%
Primary and specialty
care visit
$30 20% after plan deductible 50% after plan deductible
Hospital inpatient
(per admission)
$500 $500 + 20% after plan deductible $1,000 + 50% after plan deductible
Outpatient surgery
(per procedure)
$250 20% after plan deductible 50% after plan deductible
Emergency care $150 Covered under the HMO tier Covered under the HMO tier
Prescription drugs
Generic $10 $20 preferred, $50 nonpreferred Not covered
Brand $30 $40 preferred, $50 nonpreferred Not covered
Specialty 20%, not to exceed $250 30%, not to exceed $250 Not covered
Emergency ambulance
services (per trip)
$150 Covered under the HMO tier Covered under the HMO tier
CT/PET/MRI (per procedure) $100 20% after plan deductible 50% after plan deductible
Lab/X-ray (per encounter) $10 20% after plan deductible 50% after plan deductible
Durable medical equipment 30% 30% after plan deductible 50% after plan deductible
Fertility services $30 20% 50%
Prenatal care and
well-baby visits
No charge No charge 50%
Optical hardware Not covered Not covered Not covered
Prosthetics and orthotics No charge 20% after plan deductible 50% after plan deductible
1. The HMO tier of the point-of-service (POS) plan is underwritten by Kaiser Foundation Health Plan, Inc. (KFHP), while the participating provider
and nonparticipating provider tiers of the POS plan are underwritten by Kaiser Permanente Insurance Company (KPIC). KPIC is a subsidiary of KFHP.
2. Telehealth — Telehealth services include scheduled phone and video visits, as well as email consultations, when appropriate and available.
29
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Overvi ew HMO DHMO CDHC POS/PPO
Compare plans
Plans selected:
Complete Suite category
PPO
1
NCAL/SCAL plan ID 13898/13899 13902/13903
Tier Participating Provider Nonparticipating Provider Participating Provider Nonparticipating Provider
Plan deductible
(individual/family)
$500/$1,000 $1,500/$3,000 $750/$1,500 $1,750/$3,500
Out-of-pocket maximum
(individual/family)
$3,500/$7,000 $7,000/$14,000 $5,000/$10,000 $10,000/$20,000
Telehealth
2
$20 40% after deductible $30 40% after deductible
Preventive care $0 40% $0 40%
Primary and specialty
care visit
$20 40% after deductible $30 40% after deductible
Hospital inpatient
(per admission)
$250, then 20% after
deductible
$500, then 40% after
deductible
$250, then 20% after
deductible
$500, then 40% after
deductible
Outpatient surgery
(per procedure)
$100, then 20% after
deductible
$150, then 40% after
deductible
$100, then 20% after
deductible
$150, then 40% after
deductible
Emergency care
$150 copay per visit, then
20% after deductible
Covered under the
participating provider tier
$150 copay per visit, then
20% after deductible
Covered under the
participating provider tier
Prescription drugs
Generic
$15 for up to a 30-day
supply
Not covered
$15 for up to a 30-day
supply
Not covered
Brand
$40 for up to a 30-day
supply
Not covered
$40 for up to a 30-day
supply
Not covered
Specialty 30%, not to exceed $250 Not covered 30%, not to exceed $250 Not covered
Emergency ambulance
services (per trip)
40% after deductible
Covered as preferred
provider
40% after deductible
Covered as preferred
provider
CT/PET/MRI (per procedure) 20% after deductible 40% after deductible 20% after deductible 40% after deductible
Lab/X-ray (per encounter) 20% after deductible 40% after deductible 20% after deductible 40% after deductible
Durable medical
equipment
30% after deductible 50% after deductible 30% after deductible 50% after deductible
Fertility services 20% 40% 20% 40%
Prenatal care and
well-baby visits
$0 40% $0 40%
Optical hardware Not covered Not covered Not covered Not covered
Prosthetics and orthotics 20% after deductible 40% after deductible 20% after deductible 40% after deductible
1. The Kaiser Permanente PPO Plan is underwritten by Kaiser Permanente Insurance Company (KPIC), a subsidiary of Kaiser Foundation Health Plan, Inc.
2. Telehealth —Telehealth services include scheduled phone and video visits, as well as email consultations, when appropriate and available.
30
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Overvi ew HMO DHMO CDHC POS/PPO
Compare plans
Plans selected:
Complete Suite category
PPO
1
NCAL/SCAL plan ID 13906/13907 13910/13911
Tier Participating Provider Nonparticipating Provider Participating Provider Nonparticipating Provider
Plan deductible
(individual/family)
$1,000/$2,000 $2,000/$4,000 $1,500/$3,000 $3,000/$6,000
Out-of-pocket maximum
(individual/family)
$5,000/$10,000 $10,000/$20,000 $5,000/$10,000 $10,000/$20,000
Telehealth
2
$35 40% after deductible $35 40% after deductible
Preventive care $0 40% $0 40%
Primary and specialty
care visit
$35 40% after deductible $35 40% after deductible
Hospital inpatient
(per admission)
$250, then 20% after
deductible
$500, then 40% after
deductible
$250, then 20% after
deductible
$500, then 40% after
deductible
Outpatient surgery
(per procedure)
$100, then 20% after
deductible
$150, then 40% after
deductible
$100, then 20% after
deductible
$150, then 40% after
deductible
Emergency care
$150 copay per visit, then
20% after deductible
Covered under the
participating provider tier
$150 copay per visit, then
20% after deductible
Covered under the
participating provider tier
Prescription drugs
Generic
$15 for up to a 30-day
supply
Not covered
$15 for up to a 30-day
supply
Not covered
Brand
$40 for up to a 30-day
supply
Not covered
$40 for up to a 30-day
supply
Not covered
Specialty 30%, not to exceed $250 Not covered 30%, not to exceed $250 Not covered
Emergency ambulance
services (per trip)
40% after deductible
Covered as preferred
provider
40% after deductible
Covered as preferred
provider
CT/PET/MRI (per procedure) 20% after deductible 40% after deductible 20% after deductible 40% after deductible
Lab/X-ray (per encounter) 20% after deductible 40% after deductible 20% after deductible 40% after deductible
Durable medical
equipment
30% after deductible 50% after deductible 30% after deductible 50% after deductible
Fertility services 20% 40% 20% 40%
Prenatal care and
well-baby visits
$0 40% $0 40%
Optical hardware Not covered Not covered Not covered Not covered
Prosthetics and orthotics 20% after deductible 40% after deductible 20% after deductible 40% after deductible
1. The Kaiser Permanente PPO Plan is underwritten by Kaiser Permanente Insurance Company (KPIC), a subsidiary of Kaiser Foundation Health Plan, Inc.
2. Telehealth —Telehealth services include scheduled phone and video visits, as well as email consultations, when appropriate and available.
31
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Overvi ew HMO DHMO CDHC POS/PPO
Compare plans
Plans selected:
Complete Suite category
PPO
1
NCAL/SCAL plan ID 13914/13915 HSA Qualified 13918/13919
Tier Participating Provider Nonparticipating Provider Participating Provider Nonparticipating Provider
Plan deductible
(individual/family)
$2,000/$4,000 $4,000/$8,000 $3,000/$6,000 $5,000/$10,000
Out-of-pocket maximum
(individual/family)
$5,000/$10,000 $10,000/$20,000 $6,000/$12,000 $12,000/$24,000
Telehealth
2
$40 50% after deductible $40 after deductible 40% after deductible
Preventive care $0 50% $0 40%
Primary and specialty
care visit
$40 50% after deductible $40 after deductible 40% after deductible
Hospital inpatient
(per admission)
$500, then 30% after
deductible
$1,000, then 50% after
deductible
20% after deductible 40% after deductible
Outpatient surgery
(per procedure)
$100, then 30% after
deductible
$150, then 50% after
deductible
20% after deductible 40% after deductible
Emergency care
$150 copay per visit, then
30% after deductible
Covered under the
participating provider tier
$150 copay per visit, then
20% after deductible
Covered under the
participating provider tier
Prescription drugs
Generic
$15 for up to a 30-day
supply
Not covered
$15 after ded for up to a
30-day supply
Not covered
Brand
$40 for up to a 30-day
supply
Not covered
$40 after ded for up to a
30-day supply
Not covered
Specialty 30%, not to exceed $250 Not covered
30% after ded, not to
exceed $250
Not covered
Emergency ambulance
services (per trip)
50% after deductible
Covered as preferred
provider
40% after deductible
Covered as preferred
provider
CT/PET/MRI (per procedure) 30% after deductible 50% after deductible 20% after deductible 40% after deductible
Lab/X-ray (per encounter) 30% after deductible 50% after deductible 20% after deductible 40% after deductible
Durable medical
equipment
30% after deductible 50% after deductible 20% after deductible 40% after deductible
Fertility services 30% 50% 20% after deductible 40% after deductible
Prenatal care and
well-baby visits
$0 50% $0 40%
Optical hardware Not covered Not covered Not covered Not covered
Prosthetics and orthotics 30% after deductible 50% after deductible
20% after deductible 40% after deductible
1. The Kaiser Permanente PPO Plan is underwritten by Kaiser Permanente Insurance Company (KPIC), a subsidiary of Kaiser Foundation Health Plan, Inc.
2. Telehealth —Telehealth services include scheduled phone and video visits, as well as email consultations, when appropriate and available.
32
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Overview HMO DHMO CDHC POS/PPO
Compare plans
Plans selected:
Complete Suite category
NCAL/SCAL plan ID
Plan deductible
Individual (Self-only)/
Family member/Family
Out-of-pocket maximum
Individual (Self-only)/
Family member/Family
Telehealth
Preventive care
Primary and specialty
care visit
Hospital inpatient
(per admission)
Outpatient surgery
(per procedure)
Emergency care
Prescription drugs
Generic
Brand
Specialty
Emergency ambulance
services (per trip)
CT/PET/MRI
(per pr
ocedure)
Lab/X-ray (per encounter)
Durable medical
equipment
Fertility services
Prenatal care and
well-baby visits
Optical hardware
Prosthetics and orthotics
The plan summary highlights the most frequently asked-about benefits and is for illustration purposes only. For a complete description, please
refer to the appropriate Evidence of Coverage or Certificate of Insurance, or contact your broker or Kaiser Permanente account manager.
Information may have changed since publication.
Start over
33
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628424641 April 2021 ©2021 Kaiser Foundation Health Plan, Inc.
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